Endometriosis is a benign growth of the endometrium beyond its adequate localization (the mucous membrane of the uterine body). Genital endometriosis is one of the most common diseases of the genital organs in women, along with uterine fibroids and inflammatory diseases of the appendages.

Who is at risk?

Endometriosis is a polyetiological disease. There are several theories of the origin of endometriosis foci, the main ones being transport and embryonic.

Based on these theories, we can identify the main causes of endometriosis

Implantation and growth of endometrial cells outside the mucous membrane of the uterine body occurs against the background of hormonal and immune dysfunctions.

The main risk factors for developing the disease have been identified

• Heredity (endometriosis in mother, sister).
• Immune and hormonal imbalance.
• Late onset of sexual life.
• Inflammatory processes of the genital organs.
• Various manipulations on the uterus.
• Long-term use of the IUD.
• Late onset of menstruation.

The first signs of endometriosis

Experts have identified the most characteristic symptoms

If you experience severe pain during menstruation, heavy discharge, or discharge outside of menstruation, you should consult a doctor and under no circumstances self-medicate.

Modern diagnostic methods

Diagnosis of endometriosis is carried out on the basis of a patient interview: complaints, anamnesis (endometriosis in close relatives, childbirth, termination of pregnancy, use of an IUD, inflammatory diseases of the genital organs).

Laboratory and instrumental methods for diagnosing endometriosis

• Hormonal studies.
• Ultrasound examination.
• Colposcopy.
• Hysterosalpinography.
• Laparoscopy.
• Magnetic resonance and computed tomography.

Hormonal studies : determination of the dynamics of the concentration of FSH, LH, progesterone, estradiol.

Manifestations of uterine endometriosis during ultrasound examination: echo-negative tubular structures running from the endometrium to the myometrium, unevenness of the basal layer of the endometrium, small oval or round hypoechoic structures in the basal layer, asymmetry in the thickness of the uterine walls, an increase in its size, the appearance of areas of increased echogenicity in the myometrium and other signs

Ultrasound signs of ovarian endometriosis: finely punctate internal structure, rounded shape of the formation with a double contour, location of the formation lateral and posterior to the uterus, echo-dense capsule of the cyst, no changes in the echo structure when examined over time at different periods of the menstrual cycle.

During a colposcopic examination for cervical endometriosis, the following are noted: pseudo-erosion with hemorrhagic contents, endometriotic lesions of various shapes and sizes, polypoid lesions in the area of ​​the cervical canal.

Hysterosalpinography carried out on days 5-7 of the cycle. Signs of internal endometriosis: the uterine cavity is irregularly triangular in shape.

Laparoscopic picture of endometriosis determined by the degree of spread of the pathological focus and the duration of its existence. Modern optical technology makes it possible to diagnose foci of endometriosis in the early stages.

MRI and CT make it possible to determine the localization and nature of endometriosis. In the myometrium there are formations without clear contours, and within the pathological foci there are high-intensity signals. With ovarian endometriosis, a dense capsule with uneven contours is determined.

Experts' answers to all questions about symptoms and diagnosis

• Is there necessarily pain with endometriosis, and what kind of pain indicates endometriosis in women?

Pain with endometriosis depends on the location of the pathological focus. Nagging pain in one side or pain when lifting heavy objects may indicate the development of ovarian endometriosis. With endometriosis of the uterus, pain coincides with menstruation. The intensity of pain varies: from mild pressing or pulling to strong spasmodic.

• Could pain during intercourse be a sign of endometriosis?

Yes, with endometriosis you may experience pain during sexual intercourse.

• What kind of discharge can occur with endometriosis in women?

With endometriosis, dark (sometimes brown and even black) discharge may appear between periods. The discharge also changes during menstruation: it becomes more abundant and darker.

• How often should you be tested for endometriosis?

An annual preventive examination by a gynecologist is recommended for all women. If you have symptoms characteristic of endometriosis, you should consult a doctor as early as possible for diagnostic tests and timely treatment.

Reviews from women

The pain first appeared during menstruation. Although before endometriosis, my periods were painless. But then pain appeared even before menstruation, in the lower abdomen, in the lower back, very strong. There was also some light discharge between periods. Based on symptoms and ultrasound, a diagnosis of endometriosis was made. Now I take hormonal medications, there is no pain. If I don’t get pregnant within six months, I’ll go for a laparoscopy.

I didn’t have any symptoms as such, just pain during my period. And I thought it was normal. But I couldn’t get pregnant for 3 years. Laparoscopy revealed endometriosis.

Symptoms may vary. I had very heavy bleeding and severe pain during my period, my hormones were normal. They did hysteroscopy and ultrasound. An ultrasound showed a severe enlargement of the uterus. I am writing in the past tense, since I am currently being treated with drugs that cause artificial menopause. I feel better and hope for a full recovery.

I had irregular periods with fever and severe pain. The diagnosis was made by ultrasound, then confirmed by laparoscopy. I am currently undergoing hormone therapy. Then I plan to become pregnant.

Endometriosis is a disease of the female pelvic organs, which is characterized by a strong proliferation of tissues of the inner layer of the walls of the uterus into other structures (outside the boundaries of this organ). These cells travel to the ovaries, vagina, and other areas through the fallopian tubes, blood, and other means. Cysts can form from them, which will lead to disturbances in the functioning of the genitourinary system.

Indications

The symptoms of this disease often coincide with signs of other ailments of the genitourinary system. In some cases, it may not appear at all, or the woman may not pay attention to the symptoms, considering them unimportant or normal. Therefore, you should consult a doctor if the following phenomena are recorded:

• Long and painful menstruation
• Presence of dark-colored discharge for several days before or after menstruation
• The presence of discomfort during sexual intercourse
• Unstable cycle
• Painful urination
• Infertility
• Weakness, frequent dizziness, fatigue, skin defects
• Elevated temperature for a long time

Timing the Study

A pelvic ultrasound for endometriosis is often not enough. But this type of examination can also be useful if it is carried out at the right time.

To diagnose other diseases - fibroids and the like - it is recommended to do an ultrasound examination in the first week after the end of menstruation (from the fifth to the seventh day), when the tissues of the intrauterine layer are thinnest.

In the case of endometriosis, this principle does not work, since its formations are best visible when the inner layer of the uterine walls is thickest. Therefore, for the best result, it is necessary to do this examination from the twenty-fifth to the twenty-eighth day, if the woman’s cycle is thirty days. During this period, the endometrium becomes thickest, and, accordingly, foci of the disease grow.

Since it is not always possible to unambiguously determine the presence of this disease, it is recommended to undergo an ultrasound scan during several menstrual cycles and preferably on the same cycle days. This helps to identify signs characteristic of such a disease.

Structural changes in the endometrium

There are three main stages of changes in the state of the inner layer of the uterine walls, which are divided into several shorter mini-stages:

• First:
• Menstruation period - the thickness of the endometrium is minimal, but a number of areas may be hyperechoic
• Second:
• Days five to seven – a thin layer of the endometrium up to seven millimeters thick, with low echogenicity
• Eighth to tenth days – thickness increases to ten millimeters
• Eleventh to fourteenth days – the layer grows to fifteen millimeters
• Third:
• Days fifteen to eighteen – echogenicity increases, the layer reaches seventeen millimeters
• Nineteen to twenty-four days - the membrane thickens, echogenicity increases, and the tissue structure becomes heterogeneous
• Twenty-fourth to twenty-eighth days - thickness may decrease to 11-17 mm, echogenicity and structure remain the same

What will the ultrasound show?

Endometriosis is not always obvious on a pelvic ultrasound, but ultrasound helps determine its presence based on certain signs:

• Presence of endometrial cells in the perineum, vagina and external genitalia
• Presence of formations on the cervix
• Enlargement of the uterus, change in its shape (becomes spherical)
• Presence of cysts in the ovaries
• Thickening of organ walls

If the focus of the disease is in the ovaries, then the examination will show that:

• The tissues contain various types of nodular inclusions
• There is a round mass behind or to the side of the uterus
• Tissue heterogeneity

If the disease is localized in the uterus, then ultrasound will reveal the following changes:

• Blurred endometrial tissue
• Asymmetry of the uterine walls
• Presence of nodules

Types of disease

As endometriosis grows, its four degrees are determined:

• The first is point propagation
• Second, the lesions gradually grow
• Third - cysts form, which gradually increase in size
• Fourth – extensive damage to organs and tissues

There is also a classification according to its localization:

• Internal - lesions in the uterus and its cervix
• External - endometrial cells in the abdominal cavity, vagina, ovaries, etc.

The types of disease are distinguished according to the shape and structure of the tumors:

• Focal - a cyst with increased echogenicity up to 16 mm in size, the uterine walls are asymmetrical
• Nodular - round neoplasms up to 30 mm in size, without clear outlines and localized in a specific organ
• Diffuse - the uterus acquires a rounded outline with calcium inclusions, its inner layer has vague boundaries, the posterior wall is enlarged, and the echogenicity is increased

Diagnostic methods

A pelvic ultrasound can detect endometriosis, but doctors recommend undergoing several types of examinations to make the diagnosis as accurate as possible.

The article is under development.

Endometriosis is a functioning endometrium outside its normal location. Internal endometriosis (adenomyosis) includes fragments of the endometrium in the thickness of the myometrium, and external endometriosis includes lesions in the ovaries, utero-rectal space, uterosacral ligaments, rectum, bladder, ureters, vagina, etc.

Click on pictures to enlarge.

Endometriomas can be nodules, infiltrates and cysts, ranging in size from 1 to 40 mm. Under the influence of hormones, cyclic changes occur in them, just like in the uterus. Perifocal inflammation is a constant companion of all types of endometriosis, which leads to the formation of small adhesions around. Often the adhesive component predominates over the endometriotic component. Over time, this leads to the formation of an endometroid-scar nodule, which, having reached a certain size (3-5 mm), becomes visible on ultrasound. Visualization of “fresh” and very small formations is not possible.

Drawing. Pathomorphology of adenomyosis: in the thickness of the myometrium, endometrial glands are visible surrounded by stroma with a scar-lymphoplasmacytic reaction.

With endometriosis, the main complaint is painful, heavy and prolonged periods. Retrocervical endometriosis has the most aggressive course. Characterized by severe pain during sexual intercourse and, to a lesser extent, during bowel movements; constant aching, and during menstruation, sharp shooting pains in the lower abdomen, radiating to the sacrum, rectum, vagina, and thigh.

Diffuse form of endometriosis of the uterine body (adenomyosis) on ultrasound

A 3.5-7 MHz convex sensor is used. Position the patient lying on his back. Bladder of varying degrees of filling. Smoothly reduce the intensity of the echo-positive component of the image: many elements of the picture disappear, but high-density pathological details of the image are highlighted against a general dark background. Repeated performance of this technique from different angles ensures reliable visualization of heterotopias whose dimensions exceed 3-4 mm.

On ultrasound, the uterus is diffusely enlarged, spherical in shape, with a clear and even contour. Compared to the cervix, the echogenicity of the uterine body is increased, the myometrium is heterogeneous due to many hyperechoic point and linear inclusions, and blood flow is often diffusely increased. With TV-ultrasound, tortuous dilated vessels are often visible in the peripheral parts of the uterine wall. In half of the cases, the endometrium is thicker than it should be. In young patients, the echogenicity and echostructure of the uterus is often normal, but the uterus is always spherical in shape.

"God is in the details"

The size of the uterus can be increased in tall women, in those who have given birth many times, before menstruation, and in the presence of an intrauterine contraceptive. In contrast to endometriosis, the uterus retains an oval or pear-shaped shape, and the density of the myometrium is regarded as low.

With a pronounced bend, the size of the uterus may be larger than normal, and the shape may approach spherical. In such cases, the absence of a diffuse increase in the echogenicity of the myometrium, endometrial hyperplasia and complaints is important.

Before menstruation, the echogenicity of the uterus may decrease due to vasodilation and edema.

Diffuse fibrous changes in the myometrium during adenomyosis are often mistakenly regarded as diffuse fibromatosis of the uterus.

Table. Difference between adenomyosis and diffuse form of uterine fibroid.

	Adenomyosis	Diffuse uterine fibroma
Complaints	Algomenorrhea	More often, asymptomatic
Uterus size	Increased	Increased
Nodes	No	No
Form	Regular spherical	Irregular oval or pear-shaped
Circuit	Smooth	Wavy or finely lumpy
Myometrium	Diffusely heterogeneous due to point and linear hyperechoic inclusions	Multiple hypoechoic zones with unclear contour
Echogenicity	Diffusely increased	Hypoechoic areas
Endometrium	Often hyperplasia	Usually not changed

Local form of endometriosis of the uterine body on ultrasound

In the myometrium, individual bright hyperechoic inclusions without an acoustic shadow, irregular round, oval or blocky shape, size 2-6 mm, are found. These are areas of fibrosis around one or more endometriomas in the thickness of the myometrium. While cyclic processes occur in the foci, they can increase in size and take on the appearance of small, clearly defined nodes of irregular shape. In the local form of endometriosis, the uterus is of normal size and typical shape, the endometrium is not changed.

In almost all such cases, there is a habitual overdiagnosis of intramural fibromatous nodes with a predominance of fibrosis and calcification. Please note that the clear dependence of the lesion on the phase of the cycle indicates local fibronodular endometriosis.

Endometriosis of the cervix on ultrasound

Endometriosis of the cervix is ​​rare and does not cause pronounced manifestations. The only complaints may be bleeding before and after menstruation.

On ultrasound, cysts are detected in the myometrium of the cervix or the area of ​​the cervix is ​​thickened compared to the intact sections. The outer contour in this place is clear, smooth or wavy. The echogenicity of the cyst-free myometrium is not changed. The configuration of the neck is club-shaped, pear-shaped or fusiform. Cysts are round in shape, the wall is hyperechoic, thin, the effect of enhancement is behind, the contents are homogeneous or finely dispersed, size 4-15 mm. It is especially visible with a TV sensor.

Nabothian cysts are found in the cervix much more often than endometroid cysts. With long-term glandular pseudo-erosion, the stratified squamous epithelium of the vaginal part of the cervix covers the mouths of the glands, which leads to the formation of thin-walled cavities. Nabothian cysts are asymptomatic, very slowly increase in size to 15-20 mm, and then empty; contents are colorless, sterile, cell-free liquid. On ultrasound, Nabothian cysts are located superficially, without wall thickening and contour deformation; long-existing cysts are immersed in the myometrium.

Ovarian endometriosis on ultrasound

Ovarian endometriosis comes in two forms: endometrioid cysts and superficial endometriosis.

Endometrioid cysts can reach large sizes (up to 10-15 cm in diameter). On the smooth inner surface, compactions are found, which, upon microscopic examination, turn out to be areas of the endometrium; chocolate-colored contents. Ultrasound reveals a round formation with a double contour, the capsule in 30% of cases contains hyperechoic foci; there are no dense inclusions in the lumen, the contents are hypoechoic, homogeneous, and there is no internal blood flow. The echo structure does not change at different periods of the menstrual cycle.

Ultrasound for superficial endometriosis reveals a small (2-9 mm) hyperechoic formation of a round, oval or lumpy shape on the ovarian capsule; the contour is clear, smooth or spicule-shaped due to single short fibrous cords. The structure is homogeneous, the echogenicity is high or very high. In the affected area there is some retraction of the ovarian contour; the endometrioma is partially immersed in the ovarian tissue, but is always clearly limited from it by a thickened and compacted capsule. With purely adhesive changes paraovarian, the most typical are multiple linear hyperechoic inclusions along the edge of the ovary without retraction of the contour.

Most of these patients are observed and treated for adnexitis, and the possibility of endometrioid damage to the ovarian capsule is not taken into account. Long-term, untreated ovarian endometriosis often leads to adhesions in the pelvis, creating conditions for chronic salpingitis. It is necessary to look for hydrosalpinx/hematosalpinx and peritoneal cysts - indirect signs of adhesions in the pelvis.

Drawing. Diffuse paraovarian fibrosis as a consequence of external endometriosis.

Drawing. Under the influence of hormone therapy, the lesions shrink and can even resolve.

Endometriosis of the fallopian tubes, outer wall, round and broad ligaments of the uterus is not visible on ultrasound.

Endometriosis of the ovarian ligaments on ultrasound

TA-ultrasound is optimal with a full bladder, then the ovaries are pushed upward, the ligaments are stretched and fully included in the image. During TV-ultrasound on an empty bladder, the ovaries descend, the ligaments hang and occupy an almost vertical position in relation to the vaginal vaults, the image includes transverse and oblique sections of the ligaments, which merge with the surrounding tissues.

On ultrasound, endometriosis of the ovarian ligaments is a hyperechoic nodule or a large linear adhesion up to 30-32 mm that covers the ligament in a muff-like manner.

Deep infiltrating endometriosis on ultrasound

TV-ultrasound has a clear advantage over TA-ultrasound. During examination, the bladder is slightly full. It is necessary to determine the number, position, size (in three planes) of endometriomas, and echostructure.

Four stages of TV-ultrasound for suspected deep infiltrating endometriosis:

1. Examination of the uterus and ovaries. Assess the mobility of the uterus - normal, decreased, fixed (“question mark”);
2. Indirect signs of endometriosis: local pain and fixed ovaries increase the likelihood of endometriosis and adhesions. By applying pressure between the uterus and ovary, it can be assessed if the ovary is attached to the uterus medially, to the side wall of the pelvis laterally, or to ligaments.
3. Assess the pouch of Douglas using the “sliding sign” with dynamic TV-ultrasound. When the uterus is in anteversion, gentle pressure on the cervix using a transvaginal sensor is established as the rectum slides freely along the posterior surface of the cervix (retrocervical region) and the posterior wall of the vagina. One hand is then placed on the anterior abdominal wall to move the uterus between the palpating hand and the transvaginal probe to assess how the anterior bowel wall slides over the posterior surface of the upper uterus and fundus. When the sliding sign is considered positive in both of these anatomical regions (retrocervix and posterior wall of the uterus), it is recorded that the pouch of Douglas is not obliterated.
4. Assess the anterior and posterior cervical space.

The nodular form is a hyperechoic, compactly located heterotopia fused to each other in the space between the posterior surface of the cervix (or isthmus) and the anterior wall of the rectum. The shape of the lesion is irregular oval, less often irregular round or blocky. The contours are uneven (lumpy) and heavy. The heaviness of the contours is a consequence of adhesions and local infiltrative spread of endometriosis. The size of the lesion is from 3 to 30 mm. Retrocervical endometriosis is characterized by very high density, often with an acoustic shadow.

Drawing. Heterotopia group

The scar-infiltrative form is characterized by a significant predominance of the connective tissue component. In other words, a minor endometrioid lesion initiates the development of a pronounced adhesive process. The distribution of changes occurs along the posterior wall of the cervix: the vaginal vault, the uterosacral ligaments, the peritoneum covering the body of the uterus, the broad uterine ligament and the wall of the uterus, the anterior wall of the rectum, bladder and ureters. On ultrasound, there is a hyperechoic, heterogeneous compaction of an elongated shape - a scar cord - spreading along the posterior wall of the cervix, the anatomical and topographical features of which determine the position and shape of the changed area. The pathological focus forms a flat platform - straightening of the cervix at the level of the retrocervical lesion. The contours are heavy. Heaviness (spiculosity) is a reliable indicator of locally invasive growth.

Drawing. Perifocal inflammation appears before menstruation or immediately after its end - a hyperechoic focus is outlined by a hypoechoic rim. Perifocal inflammation is a constant companion of all types of endometriosis, but only with retrointestinal localization can it be seen with TV-ultrasound.

One of the objects of spread of retrocervical endometriosis is the uterosacral ligaments - from the posterolateral surfaces of the cervix and isthmus, cover the rectum in an arcuate manner, and are attached to the pelvic fascia of the sacrum. Isolated lesions are rare, more often secondary lesions due to ingrowth from the retroisthmus-uterorectal recess. On ultrasound, the uterosacral ligaments are not visible. A survey ultrasound is used with a weakly filled bladder, vigorous compression of the anterior abdominal wall, the beam is directed towards the intended focus - a round hyperechoic formation in one of the parametric areas at the level of the isthmus. In such patients, scar-infiltrative changes often spread to the posterior wall of the bladder, sometimes to one of the ureters - narrowing, ureterectosis, hydronephrosis.

Indirect signs of endometriosis invasion into the rectum are large size of the node, pronounced heaviness of the lower edge + pain during defecation, intensifying during menstruation, admixture of blood in the stool during menstruation.

The “kissing” sign of the ovaries indicates the presence of serious pelvic adhesions. Endometriosis of the intestine and fallopian tube is significantly more common in women with kissing ovaries versus those without kissing ovaries.

Anterior cervical space on ultrasound

Assess the anterior cervical space, where the bladder, anterior wall of the uterus and ureters are located.

We must not forget that TA-ultrasound and TV-ultrasound are complementary techniques; in the form of a two-stage study, they are a powerful diagnostic tool for diagnosing endometriosis.

It is best to scan the bladder if it contains a small amount of urine. Four zones of the bladder on ultrasound:

• (I) in the trigonal zone, which is within 3 cm of the urethral opening, the smooth triangular area is divided into two ureteral openings and the internal urethral opening;
• (ii) at the base of the bladder, which faces back and down and lies next to both the vagina and the supravaginal uterus;
• (III) the bladder dome, which lies superior to the base and is intra-abdominal;
• (IV) extra-abdominal bladder.

Bladder endometriosis is more common in the base and dome of the bladder than on the peritoneal surface of the bladder. On ultrasound, endometriosis in the anterior compartment can be variable, including hypoechoic linear or spherical lesions, with or without clear contours involving muscle (most often) or (sub)mucosa of the bladder. Bladder endometriosis is diagnosed only when the muscles of the bladder wall are affected; lesions involving only the serosa represent superficial disease.

Drawing. The four zones of the bladder are: the trigone, the base of the bladder, the dome of the bladder, and the extra-abdominal bladder. The point of demarcation between the base and the dome of the bladder is the uterine bursa.

Obliteration of the uterovesical region can be assessed using the “sliding” sign, i.e., a transvaginal probe is placed in the anterior fornix and the uterus moves between the probe and one hand of the operator placed in the suprapubic region. If the posterior wall of the bladder slides freely on the anterior wall of the uterus, then the uterine region is not obliterated. If the bladder does not slide freely along the anterior wall of the uterus, one can think about obliteration of the uterovesical area with adhesions. Adhesions in the anterior pelvis are present in almost a third of women following a cesarean section and are not necessarily a sign of endometriosis.

The distal ureters should be examined. The ureter can be found by identifying the urethra in the sagittal plane and moving the probe to the lateral wall of the pelvis. The intravesical segment of the ureter is identified and follows its course to where it exits the bladder and further to the lateral wall of the pelvis and to the level of the bifurcation of the common iliac artery. This is useful to see how peristalsis occurs and confirms the patency of the ureters.

On ultrasound, the ureters usually appear as long tubular hypoechoic structures, with a thick hyperechoic wall extending from the lateral surface of the bladder, from the base to the common iliac vessels. Ureteral dilatation due to endometriosis is caused by a stricture (either external compression or internal penetration) and the distance from the distal ureteral opening to the stricture should be measured. All women with deep endometriosis have their kidneys examined to rule out hydronephrosis as a consequence of obstruction by endometriosis.

Posterior cervical space on ultrasound

The most common posterior sites of endometriosis are the uterosacral ligaments, posterior vaginal vault, anterior rectal wall/anterior rectosigmoid junction and sigmoid colon, rectovaginal septum. On ultrasound, endometriosis in the posterior cervical space appears as hypoechoic thickening of the intestinal or vaginal wall, or as hypoechoic solid nodules that can vary in size and have smooth or irregular contours. Hypoechoic nodules may be homogeneous or heterogeneous with or without large cystic areas, or there may be no cystic areas adjacent to the nodules.

Deep endometriosis of the rectovaginal septum (the hyperechoic layer between the vagina and rectum) is confirmed by TV-ultrasound. Isolated endometriosis of the RV septum is rare, most often spreading into the vagina and/or rectum. On TV-ultrasound, the lesion is visible in the RV space under the line running along the lower border of the posterior lip of the cervix (under the peritoneum).

Drawing. Retrofrontal implants (65%) are usually a small lesion that develops from the posterior chest to, but not through, the rectovaginal septum. Hourglass-shaped implants (25%) larger lesions (>3 cm) that originate from the retrofarnital position and extend toward the anterior rectal wall. AND rectavaginal septum implants (10%) usually a small lesion separated from the cervix, located under the peritoneal fold of the cul-de-sac of Douglas.

Involvement of the posterior wall of the vaginal vault and/or lateral vaginal vault should be suspected when a nodule is visible on TV-ultrasound in the rectum in the space below the line running along the caudal end of the peritoneum of the lower edge of the rectum (the pouch of Douglas) and above the line running along the lower borders of the posterior lip of the cervix (under the peritoneum). Posterior vaginal vault or vault endometriosis is suspected if the posterior vaginal vault thickens or if hypoechoic layers of the vaginal wall are identified.

Douglas pouch obliteration can be graded as partial or complete depending on whether one side (left or right) or both sides, respectively, exhibit a negative sliding sign.

Normal uterosacral ligaments are usually not visible on ultrasound. Endometriosis of the uterosacral ligaments can be seen in a midsagittal section of the uterus. However, this is best seen by placing a transvaginal probe in the posterior vaginal fornix along the midline in the sagittal plane and then moving the probe. On ultrasound, hypoechoic thickening with clear or unclear boundaries is seen as abdominal fat around the uterosacral ligaments. The lesion may be isolated or may be part of a large nodule extending into the vagina or other surrounding structures.

Deep endometriosis involving the intestine involves the anterior wall of the rectum, rectosigmoid junction, and/or sigmoid colon, which can be visualized using TV-ultrasound. Mott take the form of an isolated lesion or may be multifocal (multiple lesions of one segment) and/or multicentric (multiple lesions affecting several segments of the intestine, i.e. small intestine, colon, cecum, ileocecal junction and/or appendix).

Histologically, intestinal endometriosis is defined as the presence of endometrial glands and stroma in the intestinal wall, reaching at least the muscular layer, where it invariably causes smooth muscle hyperplasia and fibrosis. This leads to thickening of the intestinal wall and some narrowing of the intestinal lumen. Normal layers of the wall can be visualized on TV-ultrasound: the serosa of the rectum is visible as a thin hyperechoic line, the muscular plate is hypoechoic, with longitudinal smooth muscle (external) and circular smooth muscle (internal) separated by a subtle thin hyperechoic line; the submucosa is hyperechoic; and the mucosa is hypoechoic.

Intestinal endometriosis is seen as a thickened, hypoechoic muscle wall or as hypoechoic nodules, with or without hyperechoic lesions with blurred edges. The size of these lesions may vary.

Intestinal lesions may be described according to the segment of the rectum or colon in which they occur. Lesions located below the level of the insertion of USLs on the cervix are designated as lower (retroperitoneal) anterior rectum, above this level are designated as the upper (visible by laparoscopy) anterior wall of the intestine, at the level of the uterine fundus are designated as rectal lesions, and those above the level of the uterine fundus are designated as lesions of the anterior sigmoid. The distance between the inferior edge of the most caudal lesion and the anal verge should be measured. It is possible to measure the distance from the anus to the intestinal lesion using transrectal sonography.

Hourglass-shaped nodules occur when damage to the posterior vaginal vault expands and extends into the anterior wall of the rectum. On ultrasound, the portion of the DIE lesion located along the anterior rectal wall is the same size as the portion located in the posterior vaginal fornix. There is a small but easily visible connection between the two parts of the lesion. These lesions are located below the peritoneum and pouch of Douglas and are usually large (3 cm on average).

Endometriomas may undergo decidualization during pregnancy, in which case they may be confused with ovarian malignancies on ultrasound. The simultaneous presence of other endometriotic lesions may facilitate the correct diagnosis of endometrioma during pregnancy and minimize the risk of unnecessary surgery.

Take care of yourself Your Diagnosticer!

Endometriosis is a serious disease of the female reproductive system, very often leading to a decrease in the quality of life and infertility in women. What are the diagnostic and treatment tactics for a diagnosis of endometriosis, ultrasound diagnostics, when to do an ultrasound for endometriosis, what a common complication of endometriosis - hydrosalpinx - looks like on ultrasound, we will answer these and other questions below.

Endometriosis is the growth of the inner lining of the uterus, the endometrium, in places atypical for its location. It is not for nothing that endometriosis ranks second among the causes of female infertility. This insidious disease may not manifest itself for many years, or its symptoms will not attract the attention of a woman. However, many forms and manifestations, as well as complications of endometriosis, significantly complicate its diagnosis and also worsen the quality of life of patients.

The causes of endometriosis have not been clarified to date, but there is a clear connection between various endometrial injuries and the appearance of endometriosis in the future: after abortion, curettage of the uterine cavity, operations, intrauterine contraceptives and other traumatic factors.

The manifestation of endometriosis is due to the fact that ectopic foci of the endometrium are also dependent on the hormonal background of a woman, like healthy endometrium. Thus, during menstruation, the entire endometrium is rejected, including foci of endometriosis, and subsequently its thickness increases towards the end of the cycle. This behavior of endometrioid lesions lies the answer to the question - when to do an ultrasound for endometriosis.

Depending on where the foci of endometriosis are located, its various forms are distinguished. And depending on the form, the manifestations of endometriosis differ.

Forms of endometriosis

• Adenomyosis is endometriosis of the muscular layer of the uterine body. Depending on the depth of penetration of the endometrium into the layers of the uterus, four stages are distinguished: the first is characterized by the beginning of the penetration of the endometrium into the muscular layer, with all subsequent stages the endometrium deepens towards the serous (outer) membrane, with the fourth stage it affects the serosa.
• Cervical endometriosis is characterized by minimal symptoms, since endometriotic lesions are located in the cervix. The most characteristic symptom is bleeding and pain during sexual intercourse.
• Vaginal and perineal endometriosis - endometrial lesions migrate from the uterine cavity into the vagina or perineum. At the end of the cycle, these lesions can be detected during a routine gynecological examination.
• Ovarian endometriosis – endometrial lesions are located on the ovaries and can mimic ovarian cysts.
• Tubal endometriosis – leads to obstruction of the tubes and the impossibility of conception. The blocking of the lumen of the tubes by the thickening endometrium and the development of adhesions lead to the development of a condition such as hydrosalpinx. It is not always possible to determine the cause of this condition using ultrasound; in this case, laparoscopy is performed.

Symptoms of endometriosis are repeated to varying degrees in all forms of endometriosis:

• Painful long periods, discharge of blood clots during menstrual bleeding.
• The appearance of spotting brown discharge in the middle of the cycle, a few days before and a few days after menstruation.
• Discomfort, pain during sexual intercourse, gynecological examination, physical activity.
• Pain in the lower abdomen, which begins in the middle of the cycle, reaches its apogee by the first day of the cycle, and then gradually decreases.
• Infertility of unknown origin.

How to detect endometriosis? Ultrasound diagnostics is the simplest and safest method for detecting endometrioid lesions, but it cannot always provide all the necessary answers. An erroneous diagnosis or removal of this diagnosis can occur if the answer to the question is incorrect: when to do an ultrasound for endometriosis?

To understand when to do an ultrasound for endometriosis, you need to remember what happens to the endometrium during the cycle. On the first day of the cycle, it is rejected, which is accompanied by menstrual bleeding. Immediately after the end of menstruation, the endometrium of any location is at its thinnest. That is why detecting foci of endometriosis during ultrasound diagnostics on days 3-5, as is usually done, is almost impossible due to their small size. So when should you do an ultrasound for endometriosis so that the diagnosis can be made accurately? It is best to carry out this study before menstruation, on days 23-25 ​​of the cycle - at this time the thickness of the endometrium is maximum, and the lesions will be clearly visible.

Of course, the diagnosis of endometriosis, the ultrasound diagnosis of which was carried out according to the rules, is not always possible to detect. Some forms of endometriosis are not visible on ultrasound, even if you have asked your doctor when to do an ultrasound for endometriosis and performed the test on the right day of your cycle. In this case, additional research methods will help: laparoscopy, hysteroscopy, separate curettage, analysis for markers of endometriosis.

If you cannot get pregnant for a long time, you are concerned about the listed symptoms, hydrosalpinx is detected on ultrasound - there is a high probability that you have endometriosis, ultrasound diagnostics and a thorough examination will help establish an accurate diagnosis. In this case, do not despair - the modern level of development of medicine makes it possible to successfully treat endometriosis using conservative and minimally invasive methods, which often leads to success when trying to get pregnant.

Endometriosis is not a death sentence! Even if you are suspected of having this disease, a competent doctor will prescribe a full course of examination, tell you when to do an ultrasound for endometriosis, and if the diagnosis is confirmed, will carry out a full course of treatment. In this case, the age and family situation of the patient, the desire to have children and many other factors must be taken into account. And remember - during pregnancy and menopause, a woman’s hormonal background changes, due to which a significant regression of endometriosis is possible, up to complete recovery. So don’t despair and don’t give up trying to get pregnant, and the disease will go away!

Endometriosis today is one of the most common gynecological diseases leading to long-term infertility and a decrease in the quality of life of women.

The disease is based on excessive growth of cells in the inner layer of the uterus outside of it. These cells form foci in the ovaries, on the surface of the pelvic peritoneum, and intestines.

Having the structure of the endometrium, these ectopic lesions undergo the same hormonal cyclic changes that occur in a woman’s body every month. Therefore, endometriosis has a high degree of progression in the form of an increase in the number and size of endometrioid foci (heterotopia).

There are many theories about the origin of this disease, but a single nature has not yet been identified.

Main forms and symptoms of endometriosis

According to the location of heteropias, one should distinguish between the genital and extragenital types of the disease.

In the second case, lesions are detected on the surface of the intestine and even in the navel. The genital type affects the uterus, ovaries and fallopian tubes, as well as the pelvic peritoneum, which lines the entire pelvic cavity.

The main forms of genital endometriosis are:

1. . A form of the disease in which heterotopias affect the reproductive organs outside the uterus. First of all, we are talking about the ovaries; the lesion also extends to the pelvic peritoneum and retrocervical area.
2. Internal or adenomyosis. In this case, endometrial foci grow inside the uterus into the muscular layer, and in severe cases even into the serosa. This is also often called endometriotic ducts. , in turn, is divided into 4 degrees according to the level of damage to the uterine wall.

What are the most common symptoms of different forms of endometriosis?

1. Spotting before and after menstruation. As a rule, women complain that their periods don’t seem to end. The discharge itself is dark brown in color and, as a rule, it is scanty.
2. Painful periods. different, but it always depends on the location of the foci and the degree of germination. Thus, it causes unbearable pain in women, which is difficult to relieve with medications. Patients are afraid of the arrival of the next menstruation.
3. Pain during intercourse (dyspareunia). This is a very common complaint with extragenital heteropias.
4. Infertility. External and internal diseases account for more than 20 percent of cases of long-term infertility.

Diagnostic methods for detecting endometriosis

The most common diagnostic detection methods include:

1. Ultrasound examination of the pelvic organs. This method is the simplest and most informative, does not require much time and expense;
2. Magnetic resonance imaging. Using a tomograph, it is possible to identify the location of the lesions, the degree of germination into the wall of the uterus or neighboring organs.
3. Diagnostic laparoscopy. This is the gold standard, the leading method for identifying external endometriosis, and allows you to visually assess the extent of the process. This method is also good because during the diagnostic process, the surgeon can always additionally insert an instrument and coagulate lesions on the surface of the pelvic peritoneum.
4. Hysteroscopy. This is an examination of the uterine cavity by introducing a special hysteroscope apparatus with a camera connected to it. Liquid or gas is introduced into the uterus through the system. The image is displayed on the screen. The study is carried out to assess the structure of the inner surface of the uterus. This method allows you to assess the presence and degree of endometriotic ducts in the uterus itself, determine the rigidity of the wall, and also identify additional focal pathologies of the mucous membrane. When performing hysteroscopy, the surgeon can at any time take a biopsy of the lesion that causes him doubt and send it for histological examination.
5. Colposcopy and cytological analysis of cells of the cervix and cervical canal- additional methods that are valuable in the presence of endometrioid heterotopia on the surface of the cervix.

Ultrasound examination in the diagnosis of endometriosis

A common question among all patients is whether endometriosis is visible on ultrasound. Of course, this method is quite informative and easy to implement, does not require complex preparation and is the most cost-effective.

However, you need to know that ultrasound is not indicated for all forms of the disease. For example, the external form and extragenital form will not be visible during the study; in these cases, it is worth choosing more sensitive methods - MRI and/or laparoscopy.

The indication for ultrasound for endometriosis is the need to identify the form and extent of the process.

Types of studies

Ultrasound examination in most cases is performed transvaginally; this type has high resolution due to a special sectoral sensor located close to the affected organ.

However, in some cases, transvaginal examination is complemented by transabdominal examination in order to compile a general picture of the disease.

For women who have not previously had sexual intercourse, as well as in the case of anatomical pathologies of the vagina, only a transabdominal or transrectal examination is performed. The transrectal method is preferable, since examination from the abdominal cavity is not very informative.

Preparation

On what day of the cycle is it best to do an ultrasound? Endometriosis is a cyclical process that depends on the general hormonal background. Therefore, the choice of the day of the cycle is of fundamental importance.

The best period for identifying internal adenomyosis is the second phase of the cycle, after the 20th day, and ideally on the 25-26th.

It is during this period that the endometrium reaches significant thickness and undergoes secretory transformations. The endometrioid heterotopias themselves increase in size and are well visualized.

Echo signs of endometriosis on ultrasound

It should be understood that each form of endometriosis will have its own signs on ultrasound.

— Adenomyosis (internal form) can have both diffuse and focal manifestations.

In both cases, the uterus increases in size and takes on a spherical shape. Very often, an ultrasound doctor sees a discrepancy in the thickness of the front and back walls.

In the structure of the myometrium (the muscular layer of the uterus), focal structures of different densities and areas of fibrosis that do not have a clear capsule are revealed, which is typical for the focal form of adenomyosis.

In the case of a diffuse process, there are no individual foci, but attention is drawn to the heterogeneity of the muscle wall along its entire length; the myometrium is, as it were, “eaten away.”

When examining the inner mucous membrane of the uterus in detail, attention is drawn to the unclear and uneven structure of the endometrium and the low degree of visualization of the transition of the inner layer to the muscular layer. In such cases, it is sometimes difficult for the doctor to assess the thickness of the median echo - the endometrium lining the cavity.

— External ovarian endometriosis is very visible on ultrasound.

Most of this form of the disease is represented by endometrioid cysts or endometrioma, as they are also called. With this form, the doctor sees a large formation or several formations in the ovarian tissue.

Such cysts have a uniform structure and a clear, bright capsule. Sometimes single hyperechoic (or dense) inclusions can be distinguished inside the cavity.

Such tumors do not have increased blood flow during Doppler examination. The ultrasound picture itself in this case is very characteristic, so the doctor can accurately assume the presence of an endometrioid formation. Be that as it may, the final diagnosis can only be made by a histologist after a detailed examination of the tissue area.

— External retrocervical endometriosis can be detected by ultrasound when the lesions begin to grow through the uterus into the wall of the rectum and parametrium.

The doctor notes the size of the inclusions and the mobility of the posterior wall of the cervix. Very often, a woman feels pain when traction is applied to the sensor during the examination.

The presence of retrocervical heteropias requires expanding the scope of ultrasound examination and involving related specialists.

Unfortunately, it is not possible to detect individual heterotopias on the pelvic peritoneum using ultrasound; this type of disease is an indication for more sensitive and specific methods.

Ultrasound results

After completing the study, the doctor fills out a special protocol, which records all ultrasound features and also describes the anatomy of the pelvic organs. Often the doctor attaches to the paper protocol a graphic image of the area that aroused his greatest interest.

Doppler examination of the endometrium

Doppler examination of the endometrium does not have much prognostic value; this method is usually used in identifying.

However, color mapping can help the doctor in the differential diagnosis of the nodular form of endometriosis and uterine fibroids, endometrioid ovarian cyst and other space-occupying formations.